Sara Rothstein

Hey @AnthemBCBS and @Accredo - I’m having major problems getting my Rx covered. Each of you says the other are supposed to cover it. I’ve spent 2 weeks and many hours in the phone trying to resolve this without success. Can you help?

@khemp64 It depends on which networks are being used and how the deal is structured

Curious about whether they do not get those prices when they act as TPA.

@N_Brennan Congratulations!

Some personal news. I'm a Fed again! I'm at @CDCgov as Senior Advisor to @CDCDirector - my work will focus on ensuring the success of CDCs Data Modernization Initiative. Hugely grateful to @ToddGottula and @jpdrouin for the opportunity @ClarifyHealth - will miss everyone a lot!

Cool cool. My health insurance company is experiencing a “tech glitch” and every single doctor in NY is coming up as out of network. Literally every single doctor.

@ahandvanish Star Spinner Tarot Cards By Trung Lê Capecchi-Nguyễn. I got them as a gift and tarot isn’t my thing so I’m not an expert, but they were quite aesthetically beautiful

Any recommendations for beautiful, unique artist-created tarot decks? Weird, non-commercial?

@onceuponA Is the question whether MCOs get a pmpm for non-utilizers? At least in MA, and prob elsewhere, yes, MCOs/ACOs get a pmpm from MassHealth based on rating category

This is something I've asked a number of folks about, but haven't found satisfying answers on—how do MCO contracts tend to treat "never-utilizers"? Particularly important in states that aren't enforcing some kind of clawback for Medicaid MLR.

@nikillinit There are far fewer billing codes for dental care than for medical care. Also, far fewer insurers and a lot less variation in what’s covered insurer to insurer.

Is it because there’s less variance in the care that’s needed per visit, is there more information encoded in the data standard to answer this, etc ?

I’ve gone to the dentist a couple times this year and I’m always impressed by how quickly they know whether insurance will cover something or not - it’s not a whole thing where you discover these things after the fact Why are eligibility checks so much smoother here vs medical?

@JoshGoodman_BU @rothstein_jesse @JetBlue Yup, it’s thunderstorm season on the east coast. On good weather days, things are more or less fine enough, but even a short intense storm can wreak havoc. Safe travels!

@nikillinit Sort of, but there isn’t the disruption one would expect for the level of frustration . . .

anecdotally based on talking to folks, it does seem like the tension between self-insured employers and the third-party administrators they work with has reached an all time high

@NYHammond Yes! Thank you!!

@_SaraRothstein Is this the chart you had in mind? aei.org/carpe-diem/cha…

Can someone remind me where I can find the chart that shows healthcare costs rising faster than costs in other industries? I can’t remember who publishes this chart

@DaniaPal I’m so sorry. I hope you recovery quickly!

COVID isn’t over. I tested positive on Wednesday — after three years of evading COVID. I still mask indoors and don’t eat inside restaurants. I will continue those precautions because there are many still at risk of death from COVID and we know too little about Long COVID.

@dp_oneill @costplusdrugs It would be interesting to explore the fiduciary duties of ERISA plans that permit this kind of billing.

One truly exasperating behavior in U.S. healthcare is a provider taking a product so cheap it doesn’t need to be insured, marking it up wildly, and then griping about coverage rules. Brought to you by CVS charging >$200 for a generic Rx that retails for $12.90 on @costplusdrugs.

@mayakauf @ZachWritesStuff nytimes.com/2023/05/13/us/…

@ZachWritesStuff What is this from?

@alexanderchee Wait, the series will end? This series has been an amazing addition to my life. I’d be so sad if it ends.

@DaniaPal That’s my guess too, but the lack of info is really something.

@_SaraRothstein Perhaps the customer network is the affiliated health system or a subset of the affiliated health system. My guess is that it’s not a separate MOOP, but that there is no deductible for services received from the customer network.

I tried to get info & came up short. wanted to know if the Customer network had a separate MOOP from other network providers. In the member portal, the SPD was outdated and didn’t mention this network and I couldn’t find the SBC. There was also no list of preferred providers.

@DaniaPal It’s a large university, which includes an affiliated health system

@_SaraRothstein Is the employer a health system?

@SabrinaCorlette Could be, but there was no info on who was in which tier. I spent 20 minutes in the member portal and found zero information. And I’ve never seen separate MOOPs for different tiers in a network.

@_SaraRothstein Could it be what they're calling a tiered network? i.e., preferred, non-preferred, out-of-network?

Insurance people: I know what In Network and Out of Network are. What the heck is this third category “customer network”? If it matters, this is a United plan through an employer (not mine).

@consultbenefits @LouiseNorris